Health inspection·November 19, 2020

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff A, RN turned the nebulizer on and exited the room with the medications. Staff A, RN did not remain with Resident #175 during the nebulizer treatment. Staff A, RN performed hand hygiene and left the room. After waiting a period of time Staff A, RN returned to Resident #175's room and gave him his pills. The nebulizer was off and sitting on the bedside table. Staff A, RN removed the nebulizer mask from the small volume chamber. She took the pieces to the bathroom and rinsed them off in the sink while wearing gloves. Staff A, RN placed them on a paper towel to dry. Staff A, RN emptied a urinal in the room, and removed the gloves and washed her hands in the sink. Resident # 175 was admitted to the facility with a diagnosis of COPD (chronic obstructive pulmonary disease), according to the facesheet in the admission record. A review of Resident #175's physician's orders reflected the following: 11/9/20 Treligy Ellipta 100-62.5-25 inhale 1 puff daily in am for COPD 11/9/20 Spiriva Respimat 2.5 mcg inhaler inhale 2 puffs daily in am for COPD 11/9/20 Budesonide 0.25 mg/2 ml susp. inhale 2 ml via nebulizer twice a day for COPD On 11/18/20 at 3:20 p.m. an interview was conducted with Staff A, RN. Staff A, RN said Resident #175 is insistent on doing his own medications. He does them at home, and so we hand him the inhalers and the nebulizer. He rinses his mouth himself after the inhaler. She said she knows the policy now; stay with the resident during the nebulizer treatment. A review of the Self Administration of Medication dated 11/9/20 reflected under safety assessment: Desire: No desire to self administer medications. On 11/19/20 at 1:01 p.m. an interview was conducted with the consultant pharmacist. She said the MAR (medication administration record) says to rinse after use, so yes, they have to rinse after using an inhaled steroid. Yes, they could get thrush. If the order for Nuplazid says give at bedtime, that is when it should be given. The residents go to bed around seven or eight o'clock there. That is when it should be given. On 11/19/20 at 1:35 p.m. an interview was conducted with the Director of Nursing (DON). The DON said the bedtime medication should be given no earlier than an hour before bedtime. The nurse should encourage the resident to follow the manufacturer's label for the medications. Unless it is care planned or he has a self administration the nurse needs to stay for the nebulizer treatment. They do need an order to self administer medications. From the time the resident said he wanted to do his medications himself, the assessment should have been done. It is done on admission. A review of the policy, Medication Administration, dated 7/20, revealed the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 14. Administer medication as ordered in accordance with manufacturers specifications. Level of Harm - Minimal harm or potential for actual harm 15. Observe resident consumption of medication. Medication requiring a waiting period between inhalations or drops: Residents Affected - Few Metered dose inhalers- follow manufacturers product information for administration instructions including acceptable wait times between inhalations. Medication timing (excludes insulin) HS 9 pm A review of the policy, Nebulizer Therapy, dated 6/20, reflected the following: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. If the nebulizer will supply oxygen to the patient, refer to policy oxygen concentrator. Policy explanation and compliance guidelines: 1. Care of the resident n. Observe resident during the procedure for any change in condition. o. When medication delivery is complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. Review of the policy, Administration of Dry Powder Inhalers, dated 7/20, revealed the following: Policy: Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so. Policy explanation and compliance guidelines: 12. Allow 1 - 2 minutes between inhalations. 13. Allow resident to rinse mouth with water when required per manufacturers recommendations and spit out. The proceeding information was reviewed at https://gskpro.com/en-us/products/trelegy/: WARNINGS AND PRECAUTIONS · (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Oropharyngeal candidiasis has occurred in patients treated with orally inhaled drug products containing fluticasone furoate. Advise patients to rinse their mouths with water without swallowing after inhalation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure that 1) temperatures of food held for meal service were taken and recorded in facility temperature logs before serving to residents for all resident units and 2) that clean dishware used for resident food service throughout the facility was stored under sanitary conditions in the kitchen. Findings included: 1. A tour of the facility kitchen was conducted on 11/16/20 at 12:22 p.m. with Staff G, Dietary Supervisor. She explained that the kitchen was not a full food production kitchen and that most of the food for resident meals was received already cooked for service from a production kitchen in a different building on the community campus. There was a walk-in refrigerator, reach in refrigerator, and reach in freezer that held items including salad items, beverages, tubs of prepared tuna and egg salad, desserts, and bread that were used to prepare some food items for residents. She explained that food for each meal was received in hot boxes and placed on steam tables in each of the facility's three dining rooms and from there the food was plated for service to the residents. The facility's Certified Dietary Manager (CDM) joined the tour and confirmed that already prepared food was delivered from an off-site production kitchen and generally arrives one hour before service. He confirmed the food was placed on the steam tables for holding and service. After the kitchen tour, a tour was conducted of the facility in order to locate each steam table service dining room: there was one located on the facility D wing, one located on the facility E wing, and one located on the facility RR (Rapid Recovery) wing. The service station in D wing served rooms 201-227, the service station in E wing served rooms 301-324 and rooms 401-411, and the service station in the RR wing served rooms 111-133. Each unit was observed to have a food prep pantry setup and steam table service area. A review of the document provided by the facility titled, Health Center Dining Times revealed that breakfast service for all units was from 8:00 a.m. to 10:00 a.m., lunch service for all units was from 12:00 p.m. to 1:30 p.m., and dinner service for all units was from 5:00 p.m. to 7:00 p.m. Due to precautions related to coronavirus disease 2019 (COVID-19) all residents in the facility were being served meals on trays in their rooms and the trays for each unit were prepped from the corresponding steam table service area. On 11/18/20 at 11:31 a.m. a tour of kitchen operations was conducted in order to observe kitchen staff taking temperatures of foods held for service for the lunch meal before serving. The tour and observations were conducted with Staff M, Dietary Supervisor. She stated that the prepared food for lunch service had already been delivered to each unit. The staff in the D wing service area reported they had already completed taking temperatures of the foods on their steam table. Staff M suggested going to the E wing service area. Staff H, Server was in the service area on E wing and confirmed she had not yet taken the temperatures of the foods on the line and steam table. Staff H and Staff K revealed a logbook which contained temperature logs pre-printed with the date and menu for each meal. Staff H and Staff M confirmed that facility procedure was that temperatures for food safety were taken and logged before the service of each meal. Staff H used a digital thermometer to take food temperatures and was observed performing sanitization and calibration of the thermometer prior to taking food temperatures. The cold food line was kept cooled with ice. The initial temperature reading taken by Staff H of the cottage cheese on the cold food line failed to go below 42 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which was in the danger zone for cold-holding potentially hazardous foods. Staff M stated the process when an item failed to temp in appropriate range was to flash freeze the item to bring it to proper temperature. Staff M removed the cottage cheese from the cold food line and placed it into a freezer in the service area. When the cottage cheese was returned to the line Staff H took the temperature with a reading of 37.6 degrees Fahrenheit. The rest of the food items held on the cold and hot line were within safe ranges below 41 degrees Fahrenheit for cold foods and above 135 degrees Fahrenheit for hot foods. During a follow-up tour and interview with the CDM on 11/18/20 at 2:30 p.m., temperature logs from each food service area in the facility were requested for the week of 11/15/20-11/18/20. On 11/18/20 at 3:40 p.m. the CDM provided the requested temp logs and explained that there had been an ongoing problem with staff not completing the temp logs. He stated that because of this there was an ongoing audit process in place of the food temperature logs and audit was performed once a day by a dietary supervisor. He reported that if a log was found blank during the audit, the supervisor would draw a line through it with their initials so that a staff member could not fill it in later, and the staff member was provided with education and a disciplinary write-up. He reported that the log revealed that circumstance had occurred on 11/15/20 for breakfast and lunch. Review of the log revealed that on 11/15/20 temps were not recorded for breakfast and lunch and a line was drawn through each entry area with not completed handwritten along with the staff member's name and the supervisor's initials. A copy of the written counseling provided to the staff member for the 11/15/20 failure was requested along with temperature logs for each unit for the month of November 2020, and the most recent in-service to staff on food temperature process and food safety. On 11/18/20 at 4:50 p.m. the CDM provided the facility temperature logs for November 2020. He revealed that the logs had missing entries. Regarding the entry on 11/03/20 breakfast hot items on E wing that had line drawn diagonally through with initials and temps recorded, and blank log on 11/05/20 on RR unit log that had line drawn through and not completed, he stated he discovered those failures on those days and did a verbal counseling with the staff. He stated he thought the reason staff weren't completing the temperature logs was because they were cutting corners to get the trays out since COVID means all food is trayed for rooms. The CDM revealed the written counseling form related to the staff's failure on 11/15/20 and revealed in-service records dated 09/08/20 and 10/14/20 which included subjects of log books - TCS (temperature control for safety foods) foods - temps and log-books - taking temps. The CDM said, there hasn't really been a specific focus on holding temps .but staff are educated and know the danger zone. Further review of the temperature logs provided for 11/1/20 breakfast -11/17/20 lunch revealed the following for E wing: no entry for dinner salad bar on 11/07/20 and 11/09/20 and no evidence of audit documentation. Regarding potentially hazardous foods, there was an entry of 44 flashed freezed for seafood pasta salad on lunch salad bar 11/17/20 and 46 returned for seafood pasta salad on dinner salad bar 11/17/20. The logs revealed the following for D wing: no entries for breakfast and lunch on 11/14/20; blank lunch salad bar for 11/17/20 which included temperature fields scribbled out and there no evidence of audit documentation. Every log for every unit listed cottage cheese as an item for every lunch salad bar and every dinner salad bar. Inconsistencies were revealed on logs across units with temperatures for cottage cheese recorded some days and not others and including some units recording temperatures for cottage cheese and some not for the same dates/meals. An interview was conducted with the CDM on 11/19/20 at 11:45 a.m. regarding the findings from the November temperature log review. He did not have explanation for the missing entries and did not have an answer regarding the inconsistencies for cottage cheese temperature entries on the logs, stating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm he did not know if there was a system for knowing which items were stocked on the line each day in order to ensure the staff were temping all foods including potentially hazardous food items such as dairy products. He stated that the problem with uncompleted temperature logs was identified around September 2020 due to change-overs with the nursing home administration triggering review of the logs and noting the problems. Temperature logs for all facility units for October 2020 were requested. Residents Affected - Some Review of the temperature logs for 10/04/20 - 10/31/20 revealed the following for E wing: no temperature entries for breakfast 10/08/20, dinner 10/05/20, dinner 10/06/20, and breakfast 10/17/20. Each blank log grid had line drawn diagonally through, some included initials and two included handwritten not completed with initials. Temperature logs for RR wing revealed: no temperature entries for breakfast salad bar 10/04/20, 10/07/20, 10/08/20; no temperature entries for breakfast hot food items 10/07/20, lunch salad bar 10/09/20, dinner salad bar 10/05/20, and breakfast salad bar and hot items 10/27/20. Each blank log grid had line drawn diagonally through, some included initials, and one included handwritten not completed. Temperature logs for D wing revealed: no temperature entries for breakfast hot food 10/06/10, 10/07/20, 10/08/20; no entries for lunch salad bar 10/08/20, 10/09/20, 10/10/20; no entry for lunch hot food 10/08/20; no entries for breakfast salad bar and breakfast hot items 10/15/20, 10/16/20; no entries for lunch salad bar and lunch hot items 10/16/20; no entries for breakfast salad bar 10/19/20; no entries for lunch salad bar and lunch hot items 10/25/20. Some blank log grids had line drawn diagonally through with initials and three were completely blank. 2. A tour of the small facility kitchen was conducted on 11/16/20 at 12:22 p.m. with Staff G. There was a dishwashing station that included a dish machine on the opposite wall of the kitchen from the main kitchen entrance door. On the same wall and immediately to the right of the dish washing machine was an exit/entry door to the D-wing dining room and food service station. The clean dish storage area was to the immediate right of that exit/entry door in a small corner and consisted of open shelves/racks with a ceiling vent above. The clean dish area was separated from the dish machine only by the width of the doorway, there was no barrier between the areas, and the dish storage was uncovered. The shelving was cluttered with no obvious organization and included rubber matting material that Staff G stated was meant to line shelves or trays but was observed crumpled here and there among shelves, trays, and items. Stacks of white coffee mugs were resting on a tray that also held a variety of other kitchen items and crumpled rubber liners. One of the mugs had visible drips of a brown substance down the outside. Staff G confirmed that this area was clean dish storage and that the mugs had been washed and stored there. Photographic evidence obtained. On 11/18/20 at 11:31 a.m. a kitchen tour was conducted with Staff M. She confirmed that all dishware items used for food service to the residents of the facility were washed between each meal service in that kitchen. There was a gray plastic uncovered utility cart on wheels between the clean dish storage area and the dirty dish area. Staff M confirmed the cart was being used for clean dish storage and that the dishware items and utensils on the cart were clean. There was a stack of small bowls on the cart that had visible brown food residue on the edge of two of the bowls. The surface of the cart where the dishes and the utensils had been placed was dirty: there were blobs of cottage cheese, a paper clip, crumbs, a jelly wrapper, and grime and food particles in the corners. The shelving in the clean dish storage corner had been tidied since the previous observation but remained uncovered. Photographic evidence obtained. During an interview and tour with the facility CDM on 11/18/20 at 2:30 p.m., observations made of unsanitary clean dish storage were shared. He confirmed the observations were of concern and stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he would get with maintenance to work on a solution for creating separation between the dirty and clean areas or secure covers for the clean dish storage. During a meeting with the facility Nursing Home Administrator (NHA) and the facility Director of Nursing (DON) on 11/18/20 at 2:15 p.m. for review of the facility Quality Assurance (QA) process they confirmed that the concerns identified with recording food temperatures and with sanitary dish storage had not been brought to their attention by the CDM during the survey. They confirmed there was no current active QA process or PIP (performance improvement) in those areas. They confirmed both findings were of concern and would be addressed. Review of facility policy titled Reheating of Foods dated 11/2008 revealed, If the food has been held prior to service, check food temp prior to serving. The facility policy titled Cleaning and Sanitizing preparation Areas revised 03/2009 revealed, .communities will make every attempt to maintain clean, sanitary and safe food preparation areas .Equipment should be arranged to facilitate food preparation in a safe and sanitary manner, with input from prep staff .Areas for cleaning dishes and utensils are to be located in separate areas from the food prep and service areas to maintain a sanitary environment and prevent cross contamination. According to the 2017 United States Food and Drug Administration (FDA) Food Code, Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness [which includes] improper holding temperatures. According to the Food Code, the FDA believes that maintaining food at a temperature of 57°C (Celsius) (135°F (Fahrenheit)) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness. Regarding cold food holding, the 2017 Food Code defined 41 degrees F as the standard for cold holding. https://www.fda.gov/media/110822/download, retrieved 11/20/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure a clean and sanitary environment for one resident room (216) on one of four units surveyed. Findings included: Multiple observations of room [ROOM NUMBER] on the D wing of the facility were made during the survey. On 11/17/20 at 10:05 a.m. the floor of the room was observed to have a visible film, was sticky underfoot in places, and had visible debris and crumbs around the resident's two lounge chairs. One of the chairs was upholstered with fabric and the other with leather. Both chairs had visible soiling and build-up of soil on the seats and arms and what appeared to be food particles on the cushions. One of the tray tables had visible areas where something appeared to have spilled and not been wiped down and the tray was dirty. The surfaces including the resident's dresser were cluttered and did not appear to have been wiped down. The room was observed in the same condition on 11/17/20 at 12:35 p.m., on 11/18/20 at 9:25 a.m., on 11/19/20 at 9:29 a.m., and on 11/19/20 at 3:11 p.m. when the floor appeared dirtier and the film, evidence of spill, and stickiness underfoot had spread to the area immediately inside the door. Nursing staff were observed frequently in the room assisting residents with care throughout the survey. There was no housekeeper observed on the unit during the observations. Photographic evidence obtained. On 11/19/20 at 9:29 a.m. Staff D, Certified Nursing Assistant (CNA) was observed in the room assisting one resident with breakfast. She did not have comment about the state of the room. Staff E, Registered Nurse (RN), Assistant Director of Nursing (ADON), Unit Manager (UM) was interviewed on 11/19/20 at 9:45 a.m. She stated that one of the residents in the room creates a lot of mess when he eats .spills things .he can be resistant and is particular about what he will let us do .if he accepts cleaning we go in and tidy up. She confirmed that the facility standard was that housekeeping clean every resident room every day. She stated that all CNAs and nurses were expected to tidy up and wipe down surfaces. On 11/19/20 at 3:11 p.m. room [ROOM NUMBER] on the D wing was toured with the facility Housekeeping Director. Immediately upon entering the room she confirmed that the floor had visible film and was sticky underfoot and said, I can feel it on my feet .this floor hasn't been mopped. She said the room was known as a problem room and was a hard room to keep clean including because it was hard to get the residents to leave the room in order to perform a deep clean. She said, we do the best we can .evidently they [housekeepers] have not been staying on that problem. She said her staff had been instructed to go to the nurse or to her if they were unable to clean the room and said, they have a binder with check-off sheet they turn into me. She revealed a blank check-off sheet for the D wing which had a place for the housekeeper to enter their name, the date, and check off that each resident room had been cleaned. Copies of the check-off sheets for cleaning room [ROOM NUMBER] were requested for the month of November along with facility policies. The Housekeeping Director confirmed that it was the facility expectation and her expectation that every resident room be cleaned daily. She confirmed that the daily cleaning included mopping the floors and wiping down all surfaces. She confirmed that room cleaning included cleaning of resident's personal furniture and if furniture reached an uncleanable state the family was contacted for replacement. She observed the condition of the room, visible furniture, and visible surfaces and confirmed that the status was unacceptable and said, by the looks of this room and floor it has not been cleaned today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/19/20 at 3:30 pm room [ROOM NUMBER] on the D wing was toured with the facility Director of Nursing (DON). She confirmed the state of the room was unacceptable and stated there was no reason the room should be in that condition and that any staff member should have noted that and brought it up. On 11/19/20 at 4:32 p.m. the DON followed up and provided the requested facility policy and stated that the Housekeeping Director had reported back that there were no housekeeping check-off sheets for room [ROOM NUMBER] on the D wing, that they weren't done. Review of the facility policy titled Routine Cleaning and Disinfection revised 07/2020 revealed: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The policy defined, Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Within the guidelines section, the policy revealed: 3. Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas to include, but not limited to: .c. Tray tables .i. Resident chairs .11. Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned: a. On a regular basis b. When soiling and spills occur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105926 If continuation sheet Page 10 of 10